Beneficiary - Americo

1 Administrative Office: PO Box 410288, kansas City, MO 64141-0288 Phone Fax Email Documents 18-164-1 (11/21) Page 1 of 3 Beneficiary Change Request 18-164-1 (11/21) The following is provided to assist you in designating a new Beneficiary . Please read the instructions carefully. If you have any questions, call or email us at If alterations have been made, the owner must initial by any changes. If you wish to email the completed documents: IS A NOTARY REQUIRED? A Notary is highly recommended. If this document is not notarized and signatures do not appear to match, a notary will be required by us to approve. WHO MAY NAME OR CHANGE THE Beneficiary ON A POLICY?

2 Only the owner of an insurance policy may change the Beneficiary . If an irrevocable Beneficiary has previously been named, we must have his or her signature on the change form also. If the owner of the policy is a Trust, the signature(s) and title(s) of the trustee(s) are required. If the owner of the policy is a corporation, partnership or business, two company officer signatures and titles are required (President, Vice President, Secretary, etc.). If the owner of the policy is a sole proprietorship, the sole proprietor must sign. *If the policy has a joint owner, they must also sign. If your plan is a Qualified 403(b) Annuity, your spouse must sign. WHO MAY BE NAMED AS A Beneficiary ? The Beneficiary may be one person, more than one person, a Trust, a corporation, or any other entity which will be able to obtain legal receipt of the proceeds of the policy or contract.

3 If this is a Qualified Plan, Beneficiary changes may be restricted by IRS regulations. WHAT IS THE DIFFERENCE BETWEEN A PRIMARY Beneficiary , CONTINGENT Beneficiary , AND A TERTIARY Beneficiary AND HOW ARE PROCEEDS ALLOCATED AMONGST MULTIPLE BENEFICIARIES? The Primary Beneficiary is the party who will receive the proceeds of the policy when the insured passes away. The owner of the policy may indicate, by percentage, how the proceeds are to be divided among the parties. If no indication is made, then the proceeds are divided equally among the primary beneficiaries. A primary Beneficiary is required on this form, even if changing a contingent or tertiary Beneficiary . The Contingent Beneficiary will receive the proceeds if the primary Beneficiary (ies) should pass away before the person whose life is insured.

4 Unless otherwise provided, the contingent Beneficiary will only receive proceeds from the policy if all of the designated primary beneficiaries have predeceased the insured. The Tertiary Beneficiary will receive the proceeds if the primary Beneficiary (ies) AND the contingent Beneficiary (ies) should pass away before the person whose life is insured. HOW DO I NAME A TRUST AS MY Beneficiary ? Provide the name, date, and address of the Trust where indicated on the Beneficiary Change form. Trust documents will be required in order to process a claim on this policy. If you would like us to keep a copy of the Trust documents on file, please send a copy to us. Certificate of Trust, if applicable, can be accepted in lieu of Trust documents.

5 If the Trust named is a Testamentary Trust, please indicate this on the form and do not include a Trust date. CAN I NAME MY CHILD AS A Beneficiary ? If the policy owner wishes his or her children to receive life insurance proceeds, the children themselves can be named. However, because benefits are payable to minors in only certain situations, it is recommended that a Trust be established to their benefit. To name a Trust as Beneficiary for minor children, we need the name, date, and address of the Trust. Administrative Office: PO Box 410288, kansas City, MO 64141-0288 Phone Fax Email Documents 18-164-1 (11/21) Page 2 of 3 Beneficiary Change Request 18-164-1 (11/21) Policy Number Owner s Name Insured s Name Street Address (Include City, State, and ZIP) Phone Number Owner s Email Address Subject to the provisions of the Policy and the rights of any Assignee of Record with the Company, it is requested that the Beneficiary be changed as follows: (Please print legibly in all sections) Beneficiary DESIGNATIONS (All percentages for each type of Beneficiary must equal 100%) Select One.

6 Primary Contingent Tertiary Legal Name/Trust Name/Company Name Relationship to the Insured Share of 100% Street Address (Include City, State, and ZIP) Date of Birth/Trust Date Social Security Number/TIN Phone Number Email Address Select One: Primary Contingent Tertiary Legal Name/Trust Name/Company Name Relationship to the Insured Share of 100% Street Address (Include City, State, and ZIP) Date of Birth/Trust Date Social Security Number/TIN Phone Number Email Address Select One: Primary Contingent Tertiary Legal Name/Trust Name/Company Name Relationship to the Insured Share of 100% Street Address (Include City, State, and ZIP) Date of Birth/Trust Date Social Security Number/TIN Phone Number Email Address If this request shall make any provision for children of any person as a class, the phrase shall include only lawful children of that person, including any legally adopted child, except as the term child or children shall be otherwise specifically defined in the request.

7 X X Signature of Policy Owner Date Signature of Joint Policy Owner or Spouse* (see instructions) Date Notary Acknowledgement (See Instructions) State of _____ County and or City of _____ On this ____ day of _____ in the year _____ before me, _____ [Name of Notary], a Notary Public in and for said state, personally appeared _____ [Name of Individual], known to me to be the person who executed this document, and acknowledged to me that he/she executed the same for the purposes therein stated.

8 _____ [Notary Public] Administrative Office: PO Box 410288, kansas City, MO 64141-0288 Phone Fax Email Documents 18-164-1 (11/21) Page 3 of 3 Beneficiary Change Request 18-164-1 (11/21) Policy Number Owner s Name Insured s Name ADDITIONAL BENEFICIARIES (Please select one of the designation types for each additional Beneficiary ) Select One: Primary Contingent Tertiary Legal Name/Trust Name/Company Name Relationship to the Insured Share of 100% Street Address (Include City, State, and ZIP) Date of Birth/Trust Date Social Security Number/TIN Phone Number Email Address Select One: Primary Contingent Tertiary Legal Name/Trust Name/Company Name Relationship to the Insured Share of 100% Street Address (Include City, State, and ZIP) Date of Birth/Trust Date Social Security Number/TIN Phone Number Email Address Select One.

9 Primary Contingent Tertiary Legal Name/Trust Name/Company Name Relationship to the Insured Share of 100% Street Address (Include City, State, and ZIP) Date of Birth/Trust Date Social Security Number/TIN Phone Number Email Address X X Signature of Policy Owner Date Signature of Joint Policy Owner or Spouse* (see instructions) Date Notary Acknowledgement (See Instructions) State of _____ County and/or City of _____ On this ____ day of _____ in the year _____ before me, _____ [Name of Notary], a Notary Public in and for said state, personally appeared _____ [Name of Individual], known to me to be the person who executed this document, and acknowledged to me that he/she executed the same for the purposes therein stated.

10 _____ [Notary Public]